VOL: 99, ISSUE: 07, PAGE NO: 54
Maurice Madeo MSc, BSc, is clinical nurse specialist at Hull Royal Infirmary
Maurice Madeo MSc, BSc, is clinical nurse specialist at Hull Royal Infirmary
Health care-associated infections (HAIs) cause considerable morbidity and mortality and also have resource implications for the NHS. Prevalence studies indicate that about 20 per cent of patients in hospital have infections and that nine per cent have acquired the infection during their hospital stay (National Audit Office, 2000).
HAIs have been estimated to kill about 5,000 patients a year (NAO, 2000) and in the UK it has been estimated to cost the health service £1,000m per annum (Plowman et al, 1998).
Infection control is critically important in the effective delivery of health care services. In The NHS Plan there is increasing emphasis on gaining patients’ views of their treatment, in order to try and deliver improved quality of care (Department of Health, 1999).
Isolating patients with infections is a common practice on many wards and, therefore, it is essential that nurses have an understanding of what patients might experience when isolation is recommended.
Controlling the risk of cross infection
solation nursing aims to control and minimise the spread of micro-organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile and vancomycin-resistant enterococcus (VRE). Patients who are identified as being infected or colonised by potentially pathogenic micro-organisms are usually nursed in source isolation or barrier nursed.
Effects of isolation on patients Isolation facilities usually comprise a single room with or without en suite facilities. Patients requiring source isolation as a result of an infectious disease not only have their routine disrupted but are exposed to further stress that can lead to emotional and behavioural manifestations.
Infectious isolated patients are prone to loneliness and depression as well as feeling stigmatised (Oldman, 1998; Kennedy and Hamilton, 1997; Knowles 1993; MacKellaig, 1987). One of the negative effects of isolation is the removal of familiar objects and routines, which may evoke fear, anxiety, depression, and rapid mood changes (Kennedy and Hamilton, 1997; Knowles, 1993).
The stigma of isolation
A stigma has been described as an attribute that makes a person different from the rest of the general population (Goffman, 1963). Patients feel that the stigma of the diagnosis of an infectious disease affects the attitudes of staff, which in turn affects their care (Oldman, 1998; Knowles, 1993). Patients diagnosed with an infectious disease often associate this with being dirty or unclean (Oldman, 1998). Health psychology research has shown that patients who attribute the cause of their illness to other people often experience very negative emotional outcomes, such as depression and anger. This is pertinent to hospital acquired infection where it is possible that patients may hold the hospital or individual health professionals responsible for their infection. One of the most obvious examples of stigmatisation is the display of the patient’s diagnosis on a sign on the patient’s door. This is a difficult issue because the patient has the right to confidentiality, but nurses have a duty of care to protect other patients from exposure to the infection. Stigmatisation can be made worse by the over-zealous application of infection control measures, such as the use of protective clothing when treating the patient, which can add a further barrier to effective communication. In an exploratory study using in-depth interviews with nurses and patients in isolation, Knowles (1993) also found infectious patients felt they were a danger to themselves and others, which was exaggerated by the inappropriate use of protective clothing. Madeo (2001) in a recent study found a number of patients made comments such as: ‘It made me feel like I was a dirty, unclean person seeing the doctors and nurses coming into the room wearing aprons and touching me with gloves’ (Box 1).
MacKellaig (1987) suggests ways in which the isolation room can be organised to make the environment as normal as possible in order to maintain orientation (Box 2). Staff need to encourage patients to express any negative feelings associated with being in isolation so that prompt strategies can be implemented.
Isolating patients may reduce the variety of sensory input available to them and boredom may easily become a problem. However, the literature suggests that being in isolation is not always a negative experience and some patients welcome the opportunity for privacy (Newton et al, 2001). Wilkins et al (1988) found that patients admitted to an infectious disease unit did not develop any deleterious mental changes attributed to isolation. Madeo (2001) found that a number of patients preferred the solitude of isolation as they were guaranteed a good night’s sleep. The preference for isolation appears to depend on the patient’s normal social environment.Patients isolated for longer periods of time, such as one week, appear more susceptible to developing altered mood states that can manifest as depression and withdrawal (Madeo, 2001; Oldman, 1998). Kennedy and Hamilton (1997) in a study of MRSA-positive patients on a spinal cord injury unit found that the patients studied believed their treatment had been compromised because of their infection.
It is not unusual to find isolation rooms on wards situated away from the nurses’ station, making it difficult to attract nurses’ attention as well as being unsuitable for maintaining mental stimulation (Knowles, 1993). It has been reported that even if a call bell is made available to patients, there can be a delay in staff responding to it, which can leave the patient feeling angry and neglected (Madeo, 2001; Knowles, 1993).
In a recent audit it was found that patients who had television, radio and newspapers were more satisfied, although the use of videos and DVDs also needs to be considered (Madeo and Owen, 2002).
The possible use of pet therapy should also be discussed with the infection control team.
Another problem with patients in isolation is that voluntary groups such as the hospital’s mobile library may ignore them, which can perpetuate feelings of social deprivation.
It is important to involve visitors and staff as both have a major role to play in relieving the boredom and lack of social interaction commonly experienced by these patients. Frequent visits from staff during the day help to relieve boredom and remove feelings of neglect. Visitors should also be encouraged to spread their visiting times throughout the day.
Gammon (1999) has identified the benefits of giving patients with infectious conditions adequate information to reduce stress and anxiety and to help cope with isolation. Information appears to enable patients to take more control and to comply with medical treatment (Latter et al, 1992). In a quasi-experimental study Gammon (1998) found that preparatory information influenced patients’ ability to cope with being isolated because it helped to reduce anxiety and depression.
Madeo (2001) found that visitors and relatives are not always given adequate information about the reasons for isolation or about the particular infection, resulting in unnecessary anxiety. Failing to meet patients’ needs for information could in part be related to staff’s poor knowledge of micro-organisms and infection control practices leading to unnecessarily complicated isolation precautions (Horton, 1993).
Information is particularly important for patients with infections who may be asymptomatic and who may find it more difficult to accept the required infection control measures. This may lead to confusion about the severity and the efficacy of their treatment (Newton et al, 2001). One solution to improve communication and instigate appropriate management of isolated patients is an infection control link nurse. The link nurse can act as a positive role model to empower staff to develop good infection control practice (Ching and Seto, 1990).
Leaflets can help to support explanations, but they must not be used as a substitute for verbal information as they can be mislaid (Perry and Grove, 1997). In an audit of the usefulness of leaflets (Madeo and Owen, 2002) one patient stated: ‘I have been given a good understanding and know that my relatives are not at risk unless they have an open wound.’
Isolation with an infectious disorder reduces choice for patients, as they will be physically restricted from interacting with other patients and staff on the ward. It is, therefore, essential that effective measures are in place to improve the quality of care delivered to this group of vulnerable patients is in place. This article has addressed only some of the problems associated with caring for a patient in source isolation. It highlights the need to assess patients individually and plan their care to minimise the risk of cross infection as well as safeguarding against negative psychological effects.